| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
841 |
328 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,309 |
1,283 |
$35K |
| D1120 |
Prophylaxis - child |
829 |
813 |
$28K |
| D1110 |
Prophylaxis - adult |
534 |
521 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,498 |
1,473 |
$21K |
| D0274 |
Bitewings - four radiographic images |
570 |
554 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,689 |
1,124 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,347 |
1,285 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
107 |
104 |
$14K |
| D1351 |
Sealant - per tooth |
495 |
93 |
$12K |
| D0272 |
Bitewings - two radiographic images |
371 |
364 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
107 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
13 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
32 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
114 |
$4K |
| D0240 |
|
153 |
81 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
53 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$225.36 |
| D0603 |
|
1,947 |
1,896 |
$142.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |